Prior authorization

Authorization Rules Engine 

Advanced, Configurable Rules Engine: Determines if a service requires prior authorization by evaluating requests based on payer-specific rules, benefit plan design, procedure codes, diagnosis, and place of service. 

Supported Guidelines: Aligns decisions with CMS National and Local Coverage Determinations (NCD/LCD), third-party guidelines, and proprietary payer criteria and policies.

Customization Capabilities: Configure PA criteria by plan, provider group, or line of business; manage rule variations based on geography or utilization patterns.

Intake & Submission Automation

Broad Intake Channels: Supports EDI 278 transactions, secure provider portals, fax-to-digital ingestion, and APIs. 

Intelligent Data Extraction: Auto-populates PA request forms by parsing structured and unstructured clinical data from visit notes, CCDs, and PDFs, using NLP models trained to extract key clinical elements.

Validation & Accuracy Controls: Includes pre-submission checks for missing data, mismatched coding, or unsupported requests, along with payer-specific validation logic to reduce rejections and pends. 

Decision Support & Adjudication 

Automated Triage: Enables automated triage and initial screening of prior authorization requests. Auto-approval logic is applied based on payer policy and documentation quality. 

Intelligent Classification: Requests are intelligently classified into recommendations for approved, denied or manual review queues if criteria are not met. 

Medical Necessity Simulation: Simulates policy-driven approval logic to highlight documentation gaps, reducing unnecessary manual review of clearly non-compliant requests. 

UM System Integration: APIs and data pipelines support integration with internal Utilization Management (UM) systems, allowing real-time handoff and return of authorization decisions and supporting documents. 

Status Tracking & Communication 

Timely Status Updates: Ensures full transparency by continuously tracking statuses like submitted, pending, approved, denied, and corrected. Available via dashboard, provider portal, or API integration. 

Customizable Notifications & Alerts: Provides customizable notifications for pending requests needing more information, denials requiring appeal, and approvals/follow-ups, delivered via email, system alert, or secure messaging. 

Intelligent Follow-Up Routing: Smart routing directs cases needing intervention to designated payer staff, triggered by aging SLAs, denial types, or missing responses. 

SLA Tracking & Escalation: Configurable SLA thresholds per service type or payer agreement, with system escalation to supervisors if aging requests exceed defined timeframes.